The Science Journal of the American Association for Respiratory Care

1996 OPEN FORUM Abstracts

Successful Application of the Respironics BiPAP^{TM} S/T Device for Ventilation of Two Premature Neonates Via Tracheostomy For Transition to a Home Care Setting.

Thom Belda RRT P/P Resp. Specialist Garth Asay M.D. Mayo Eugenio Litta Children's Hospital, Rochester, MN.

Background: Currently, the only available in-home portable ventilators are relatively insensitive to very small infants respiratory demands. These home ventilators do not provide continuous flow as do infant ventilators designed for the intensive care setting. This major limitation makes them ill-suited for providing mechanical ventilation to infants needing positive pressure ventilatory support apart from an intensive care setting. This is especially true in cases involving neuromuscularly challenged patients. Furthermore, it is not practical to employ ventilators designed for the Neonatal "ICU" in the home care environment. Introduction: We report a case in which two premature male neonates born at our institution required the transition to home care setting involving neonatal specific, positive pressure ventilation. Each of the infants was born with Myotubular Centronuclear Myopathy. The clinical course of this disease often includes progression to complete respiratory failure due to extreme muscle weakness. This neuromuscular disease is very rare and often fatal unless the commitment to continuous mechanical ventilation is made. The first of these infants was born at 30 weeks and the other at 34 weeks gestational age. Each of these infants survived the newborn period but, it was determined that weaning from ventilatory support would not be possible. Each patient underwent tracheostomy to facilitate pulmonary hygiene. We then sought out all available options to provide cost effective, home mechanical ventilatory support that was infant specific Methods: By modifying the patient interface and circuit of a BiPAP^{TM} device, we found it possible to take advantage of the continuous flow characteristics and pressure limited delivery of ventilatory support similar to that found in full featured neonatal ventilators. In each of the two situations the circuit consisted of a smooth inner lumen tubing with a heated "wick" type of humidifier and a water trap in line. An Isothermal Omni-Flex^{TM} connector (Baxter Healthcare Corp.) was attached to the "whisper swivel" exhalation port as the circuit connection to the trach tube. Mechanical deadspace was reduced by shortening the length of the "whisper swivel" design. A desired leak around the tracheostomy tube was present and well compensated for by the mechanics of flow delivery of the BiPAP^{TM} device. Oxygenation was maintained by adding low flow oxygen in to the ventilator circuit as needed. IPAP was adjusted to provided adequate expired tidal volumes (Vt) = 6-9 ml/Kg as measured initially by a Bicore^{TM} CP-100 Neonatal monitor. This monitor also confirmed synchronous ventilation of each patient as represented by pressure and flow waveforms. Positive End Expiratory pressure EPAP was maintained at 4 CmH2O. Airway pressures were measured using a Novametrix(r) Pneumogard mean airway pressure monitor which also functioned as the disconnect alarm. The timed mode was selected to deliver a background rate. Percent IPAP was set at 15% in each case. Evidenceof effective ventilation was observed by monitoring of Hr., RR., BP., TcPCO2, SpO2 and blood gasses. Each infant was maintained on this form of ventilatory assist for the duration of their hospital stay. A respiratory home care provider outfitted the home's of these patients with a BiPAP^{TM} S/T device and a Respironics Airway Pressure Monitor. Discussion: To date, there continues to be a lack of appropriate home ventilatory assist devices for infants and most notably for infants with neuromuscular respiratory failure. Our experience indicates that the BiPAP^{TM} device may be modified to safely deliver intensive positive pressure ventilation to patients of this select infant population

Reference: OF-96-019

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